Sexual and gender minority health in the Middle East and North Africa Region: A scoping review

Background Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems. Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa. Objectives We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities. Design We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool. Data sources We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid). The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority). Each was operationalized using multiple search terms and, where available, controlled vocabulary terms. Review Methods Research articles were identified and assessed for inclusion using an explicit strategy. Relevant information was extracted and synthesized to present a descriptive summary of existing evidence. Results Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5). Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32). Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%). Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study. Conclusion Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence. More research is needed from countries outside of Lebanon, Pakistan, and Iran, including community-based participatory approaches and multi-level intervention development. Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

Background: Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems.Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa.Objectives: We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.Design: We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.Data sources: We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid).The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority).Each was operationalized using multiple search terms and, where available, controlled vocabulary terms.Review Methods: Research articles were identified and assessed for inclusion using an explicit strategy.Relevant information was extracted and synthesized to present a descriptive summary of existing evidence.Results: Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5).Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32).Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%).Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study.

Conclusion:
Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence.More research is needed from countries outside of Lebanon, Pakistan, and Iran, including communitybased participatory approaches and multi-level intervention development.Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

Background
Sexual and gender minority, also known as lesbian, gay, bisexual, transgender, and queer people, experience high rates of violence, stigma, and discrimination (Rothman et al., 2011;Sadika et al., 2020;Williams et al., 2021), lack of cultural competence in health care settings (Alencar Albuquerque et al., 2016;Lerner and Robles, 2017;Lisy et al., 2018), and high rates of health disparities (Williams et al., 2021;Zeeman et al., 2019).These health disparities are attributable to multiple minority stressors (Meyer, 2003) that function at the structural (anti-sexual and gender minority policies and laws), interpersonal (victimization, discrimination), and individual (internalized stigma, identity concealment) levels and contribute to increased stress and health burdens (Hafeez et al., 2017;Hatzenbuehler, 2016;Lamontagne et al., 2018;Pachankis et al., 2017;Pachankis et al., 2020).Previous researchers have found higher rates of depression, anxiety, suicidal ideation, alcohol and drug use, human immunodeficiency virus (HIV) risk behaviors, and unhealthy coping mechanisms among sexual and gender minority people compared to heterosexual and cisgender people (Flentje et al., 2020;Hatzenbuehler and Pachankis, 2016;Richman and Hatzenbuehler, 2014).A cisgender individual is defined as someone whose gender identity is congruent with their sex assigned at birth.For example, sexual minority men are twice as likely as heterosexual men to report a lifetime history of depression and anxiety (Cochran and Mays, 2009;Meyer, 2003).Despite growing evidence related to these health disparities in North America and Europe, we know little about the health of sexual and gender minority people living in the Middle East and North Africa.
Many countries in the Middle East and North Africa have laws that criminalize same-sex behaviors or relationships.For example, Article 534 of the Lebanese Criminal Code states that "any sexual intercourse contrary to the order of nature" is punishable with up to a year in prison (Al Farchichi and Saghiyeh, 2021).In Iran, same-sex relations are illegal, but the country allows transgender individuals the right to have their identity lawfully recognized.However, this recognition is conditional based on a psychiatric diagnosis of gender identity disorder and the completion of gender affirmation surgery (which is subsidized by the government) (Being Transgender in Iran 2016).These laws create structural stigma, which is defined as "societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and wellbeing for stigmatized populations" (Hatzenbuehler and Link, 2014p.2) and compound the complex forms of minority stress at the intrapersonal and interpersonal levels that sexual and gender minority people face.Stigma and discrimination have been identified as contributing to the persistent health disparities among sexual and gender minority people (Human Rights Watch 2018).
Social, religious, and political contexts in some parts of the Middle East and North Africa have shifted over the past decade towards intolerant forms of conservative extremism that have set back the work of community activists towards sexual and gender minority rights (Human Rights Watch 2018;Masri, 2020).At the same time, we have witnessed a rise in advocacy for sexual and gender minority rights from grassroot activists, community organizers, and professional groups (Human Rights Watch 2018;Masri, 2020).Despite a parallel increase in research, many gaps in knowledge remain related to sexual and gender minority health.
As the largest healthcare profession, nurses should play a significant role in reducing health disparities among vulnerable populations such as sexual and gender minority people.With the significant impact of social determinants on health and wellbeing, nurses should be adequately trained in providing safe and competent care (World Health Organization 2019) and in mitigating factors that threaten the health and safety of sexual and gender minority people.However, no studies have been conducted in the Middle East and North Africa examining the role of nurses in providing care to sexual and gender minority people; in one study, researchers reported general mistrust toward healthcare providers and that they lack the appropriate training and education to provide competent care (Abboud et al., 2020).
The context in which sexual and gender minority people live in the Middle East and North Africa creates unique health disparities in this population that remain poorly understood.Therefore, the overall objective of our scoping review was to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.Implications for nurses are also discussed.

Design
Scoping reviews are appropriate when there is minimal literature on a topic, when methodological approaches are heterogeneous, and when the research question/objectives are broad in nature Arksey and O'Malley (2005).In line with the purpose of a scoping review Arksey and O'Malley (2005), we aimed to explore and map the literature for important concepts and present an overview of a potentially large and diverse number of research studies pertaining to sexual and gender minority health in the Middle East and North Africa.We used the methodological framework for scoping reviews recommended by Arksey and O'Malley (2005).The framework includes five steps: 1) identify the research question; 2) identify relevant studies; 3) select the studies; 4) extract and chart the data from the relevant studies; and 5) synthesize and report the results.We did not assess the risk of bias or the quality of the studies because, unlike systematic reviews, the aim of scoping reviews is to provide a descriptive overview of the reviewed studies and identity gaps and future research priorities (Arksey and O'Malley, 2005;Tricco et al., 2018).
Our research team included five cisgender individuals who live in the United States (US) and one in Canada whose educational backgrounds are in nursing, psychology, public health, global health, and library and information science.Half of the team identifies as lesbian, gay, or bisexual.Among those living in the US, two were born and raised in Lebanon and are closely involved in sexual and gender minority research and advocacy in Lebanon and the region.We acknowledge that our multiple identities and experiences both in Lebanon and globally inform and influence our research interests, including the aims and approach of this study.To address our biases, we met regularly, debriefed, and discussed the inclusion/exclusion criteria, data extraction and synthesis, and presentation of findings and implications to ensure the rigor of the study.

Data sources and search strategy
We searched the following databases: PubMed (through Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid).The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority).Each was operationalized with multiple search terms and, where available, controlled vocabulary terms.In Scopus, which indexes materials from fields other than biomedicine, the search strategy included a filter based on journal subjects.Search terms for the Middle East and North Africa included the combination of names of all countries in this region and their capitals, as defined by the World Health Organization (WHO EMRO | Countries 2019) and the World Bank (Middle East and North Africa 2019).Search terms for sexual and gender minority people included various phrases used in health and social sciences research.We used and expanded upon the sexual and gender minority search terms from a recent scoping review on substance use among sexual and gender minority youth (Kidd et al., 2018) and the search terms recommended in a systematic review of sexual and gender minority search terms (Lee et al., 2016).Our search strategy was guided by the research team and designed and conducted by the fifth author, who is an experienced health information specialist.The Medline search strategy was peer reviewed by an independent information specialist using the PRESS checklist.Supplement 1 provides the search terms and syntax used.

Criteria and process
We used the following inclusion criteria: 1) studies conducted in the Middle East and North Africa based on country definitions from both the World Health Organization and the World Bank: Afghanistan, Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, or Yemen; 2) studies conducted in Israel that included Arabs/Palestinians; 3) peer-reviewed studies focused on sexual and gender minority health outcomes; 4) quantitative, qualitative, or mixed-methods designs (interventional or observational); and 5) studies written in English, Arabic, or French.Consistent with the World Health Organization's definition of health, we included any empirical paper that described a health outcome related to physical, mental, or social well-being (World Health Organization(WHO) 2019).We excluded: 1) gray literature (e.g., conference presentations, theses/dissertations, reports, commentaries or editorials, and books); 2) systematic/literature reviews; 3) articles that reported on psychometric development and testing; 4) articles that reported on healthcare professionals' or the public's attitudes of sexual and gender minority people; 5) articles that reported on population estimates of sexual and gender minority groups that did not include health outcomes; 6) studies conducted with Middle East and North Africa migrants or refugees in a non-Middle East and North Africa country; 7) studies published before the year 2000; and 8) studies conducted in Israel that did not include separate data for Arabs/Palestinians (based on the definitions of the Middle East and North Africa by the World Health Organization and the World Bank that exclude Israel and given the sociocultural differences between Arabs/Palestinians and Israelis residing in Israel).
Duplicate articles were removed after the final search was completed in March 2021, and all citations were exported to Covidence, a systematic review manager.Two independent raters, the first and fourth authors, evaluated the eligibility of all identified titles and abstracts for inclusion using Covidence.Disagreements were resolved by discussion and consensus.Full-text articles were then independently evaluated for inclusion by the same raters using the same inclusion and exclusion criteria.

Data extraction and synthesis
The following data were extracted by the first and fourth authors to summarize key features of the studies: author(s) and year of publication, country, source of funding, study objectives, methods, sample characteristics, and main findings/themes.The studies were initially grouped based on country and then regrouped based on themes of common health outcomes.The research team met regularly to discuss and organize the studies based on their main objectives to fall under the five common themes: sexual health outcomes, mental health outcomes, violence and discrimination, experiences with the healthcare system, and gender identity.We also paid special attention to methodological trends, the range and scope of the findings, and the gaps in the literature.

Results
We identified a total of 5498 articles through electronic database searches conducted in April 2020 and updated in March 2021.
S. Abboud et al.Following removal of duplicates (1680), 3818 article titles and abstracts were screened; 3556 were excluded as not relevant, leaving 262 full-text articles to be screened.After reading the full texts, 162 articles were excluded for one or more of the following reasons: studies conducted in Israel but did not include Arab/Palestinian participants (n = 97); study designs such as sexual and gender minority population estimates and did not include health outcomes (n = 21); not health-related (n = 17); study population did not include sexual and gender minority people (n = 13); conducted with Middle East and North Africa migrants/refugees but not conducted in the Middle East and North Africa region (n = 6); language not spoken by any of the co-authors (n = 6); no access to full text (n = 3); and published before the year 2000 (n = 1).Articles that were excluded because of language (five Farsi and one Hebrew) or because of no access to full text are listed in Supplement 2. After these exclusions, 98 articles were included for review (Fig. 1).

Characteristics of studies
Research designs of the studies were quantitative (n = 73), qualitative (n = 20), and mixed-methods (n = 5).As shown in Fig. 2, most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23), with the majority focused on gender minority people (transgender, transsexual, hijra [term used in Pakistan to describe gender minority individuals]; n = 58), or sexual minority men (n = 51).Several studies included both sexual and gender minority participants.With the exception of one article that was published in French, all were in English.Sample sizes ranged from three to 50 participants for the qualitative studies and from 10 to 43,522 participants for the mixed-methods and quantitative studies.Additional study characteristics are summarized in Table 1.

Themes
Five themes emerged from the review: sexual health (n = 52; 53%), mental health (n = 20; 20%), violence and discrimination (n = 7; 7%), experiences with the healthcare system (n = 2; 2%), and studies about gender (n = 17; 17%).Although in some studies, researchers assessed multiple health outcomes, we categorized them in the theme corresponding to the closest fit with their main research objective.In the following section, we report findings of the studies organized by themes.Despite the use of multiple and sometimes imprecise terminology by the authors of the studies reviewed, we chose to use the terms "sexual minority" and "gender minority" to consistently refer to the diverse samples in the studies.More detailed information about the composition of samples is found in the relevant table for each section.

Sexual health
In more than half of the studies (n = 52), researchers focused on sexual health, specifically rates, testing, and risks for HIV or other sexually transmitted infections (Table 2).These studies were primarily conducted in Lebanon (n = 23) or Pakistan (n = 17); three were conducted in Iran, two in Egypt, two in Israel, and one each in Jordan, Libya, Morocco, and Yemen.One study included participants from multiple Middle East and North Africa countries.We first describe the studies conducted with sexual minority people (n = 39), followed by the studies conducted with gender minority people (n = 21).Eight studies included both sexual and gender minority participants.

Sexual minority participants
In only one study, researchers investigated the sexual health of cisgender sexual minority women (Gereige et al., 2018).In this study, sexual minority women were compared to heterosexual cisgender women and were found to be significantly younger at sexual debut than their heterosexual counterparts (19 versus 21 years).Sexual minority women reported a significantly higher number of lifetime sexual partners (mean n = 13 versus n = 7) and experiences of unwanted sexual contact (50% versus 23%) than did heterosexual women.They were also more likely than heterosexual women to have been tested for sexually transmitted infections (22% versus 4%).
In the other studies with sexual minorities, researchers focused on sexual health among sexual minority men.Like sexual minority women, most sexual minority men had their first sexual encounter before age 18 (Mirzazadeh et al., 2014;Valadez et al., 2013;Wagner et al., 2012), and more than 10% (13.8%) reported forced sexual debut (Valadez et al., 2013).The number of sexual partners was high in most studies that assessed this outcome.In Lebanon, 78% of 2238 study participants reported more than one sexual partner (Assi et al., 2019).Other studies reported a mean of 3.9 (SD [Standard Deviation] = 5.4) (Wagner et al., 2020) and 4.8 (SD = 8.7) sex partners (Wagner et al., 2014) in the past three months, and researchers in one study of 101 participants reported that 65% had five or more sexual partners in the past year (Kassak et al., 2011).Similarly, in Egypt, the majority of sexual minority men engaged in penetrative and receptive anal sex (66%) and with more than one partner (77%); slightly over one-half (53%) reported more than three sexual partners per week (El-Sayyed et al., 2008).Most studies in Pakistan focused on sexual minority men sex workers and not surprisingly, the number of sex partners was high, ranging from 4/week to 13/month (Bokhari et al., 2007;Mir et al., 2013;Saleem et al., 2008).
One participant was co-infected with HIV.
All participants had a history of at least one sexually transmitted infection.
14 Aunon (2015); Lebanon Explore the factors influencing sexual risk behaviors and HIV testing among male sex workers.reported condomless receptive sex with a male partner who was HIV-positive or had an unknown HIV status.

Design
Of those who had insertive anal sex, 84.6% reported condomless sex and 42% reported condomless insertive sex with a male partner who was HIV-positive or had an unknown HIV status.48% reported ever having been tested for HIV.60.7% reported ever testing for any sexually transmitted infections.
Participants who saw a medical doctor in the previous year had 6 times greater odds of having an HIV test prior to the study; those who knew where to find HIV testing had less odds of reporting any unprotected anal intercourse regardless of partner status and greater odds of ever having been HIV tested.

Tohme (2016); Lebanon
To explore HIV transmission and sociodemographic correlates of condom use and HIV testing among men who sex with men refugees in Lebanon.S. Abboud et al. et al., 2016a;Tohme et al., 2016b).Among refugees, relationship status, sex work, self-identifying as gay, and fewer years living in Lebanon were predictors of HIV testing (Tohme et al., 2016b).In one study, researchers compared sexual risk behaviors between drug-using sexual minority and heterosexual men and found comparable rates of HIV testing between the two groups (40% each) (Zamani et al., 2010).Stigma, fear of being judged, negative interactions with healthcare workers, and concerns about confidentiality were among the main barriers for HIV testing reported in the studies (Alkaiyat et al., 2014;Wagner et al., 2012).

HIV, sexually transmitted infections, and condom knowledge
Knowledge regarding HIV, sexually transmitted infections, and condom use was measured differently across studies, and results were mixed.In Libya, Yemen, and Jordan, knowledge about HIV and sexually transmitted infection transmission was low (17%, 28%, and 32% respectively) (Alkaiyat et al., 2014;Mirzazadeh et al., 2014;Valadez et al., 2013).For example, in the study conducted in Libya, only 1% of sexual minority men correctly identified two common sexually transmitted infection symptoms, and only 12% knew how to use condoms correctly (Valadez et al., 2013).In Pakistan, HIV, sexually transmitted infection, and condom protection knowledge was better and ranged from 36% to 70% (Saleem et al., 2008;Shaw et al., 2011).In a study of sexual minority men in Egypt, HIV and sexually transmitted infection knowledge increased with educational level (El-Sayyed et al., 2008).

Condom use
Condom use (measured as lifetime, past six months, or last sexual encounter) varied greatly in Lebanon (46% to 70%) (Assi et al., Studies are listed chronologically in alphabetical order of countries; HIV: human immunodeficiency virus; AIDS: acquired immunodeficiency syndrome.There was a significant difference between male-to-female and female-to-male groups in terms of prevalence of personality disorders.Highest and lowest mean scores of Gender Masculine scale belonged to the female-tomale and male-to-female groups, respectively.
On the Gender Feminine scale, the female-tomale group had the lowest scores.female-to-male have dominant masculine gender role, while male-to-female have dominant feminine gender role.female-tomale scores were similar to female controls.
No one was considered androgynous.4 Valashany (2018); Iran Evaluate self-reported perceived quality of life in female to male (female-to-male) and male to female (male-to-female) transgender participants and compared to the general population.Compared to the control group, transgender participants had significantly lower quality of life in the dimensions of physical and social functioning, role limitations, and vitality.

Method
In male-to-female: significant association between hormone therapy and subscales of the physical role limitations, emotional health, and social functioning; and significant association between surgical intervention and subscales of physical functioning, vitality, emotional health, and social functioning In female-to-male: significant association between hormone therapy and with subscales of vitality, emotional health, social functioning, and pain; and significant association between surgical intervention and the subscales of physical role limitations, vitality, emotional health, social functioning, and pain.Childhood sexual abuse was correlated with more types of sexuality-related discrimination in the past year and with ever been in an abusive relationship, compared with their peers who did not report being sexually abused as a child.Sexual abuse post-childhood was correlated with weekly use of marijuana, a greater number of substances used in the past 3 months, greater number of types of sexualityrelated discrimination in the past year, having been in an abusive relationship, and reporting a greater number of male sex partners in the past 3 months, in comparison with those who did not experience post-childhood sexual violence.
2 Orr (2019); Lebanon 3 Mayhew (2009); Pakistan Investigate the nature and extent of human rights abuses against three vulnerable groups (injecting drug users and male and transgender sex workers).Abuse: All groups experienced abuse from clients and people in their neighborhoods.Among transgender and male sex workers, abuse increases the more feminized the person was.Abuse ranged from verbal abuse to physical beatings, sexual assault and rape.

Design: Mixed methods
Qualitative data: all sex worker groups were exploited by police to negotiate bribes of money or free sex from the sex workers and their managers.
6 Studies are listed chronologically in alphabetical order of countries.
In some studies, condom use was positively associated with older age and negatively associated with religiosity (Elmahy, 2018;El-Sayyed et al., 2008).Participants who reported condom use also reported feeling more worried about HIV and sexually transmitted infections than those who did not report condom use (Wagner et al., 2012).Some of the main reasons for low condom use were stigma, knowing one's partner, and not practicing anal intercourse (Alkaiyat et al., 2014).Condomless anal sex was associated with greater knowledge of HIV risk, greater perceived judgmentalism in communication about sex, greater number of types of gay-related discrimination experiences, and lower general social support (Ghanem et al., 2020;Wagner et al., 2020).

Other sexual risk behaviors
In one study (Morocco), around 65% of participants received money for sex, and 83% reported also having mostly unprotected sex with women (Johnston et al., 2013).A small percentage of male sex workers (1%) had overlapping sexual risk behaviors, defined as having sex with people who inject drugs and sharing needles (Melesse et al., 2018).Khanani and colleagues reported bridging of HIV transmission to spouses and children from sexual minority men and injection drug users through needle sharing (Khanani et al., 2011).Sexual minority men reported significantly higher rates of sharing needles or having had more than five sexual partners in their lifetime than heterosexual injection drug users (Zamani et al., 2010).In a comparative study between Arab and Jewish sexual minority men, Arabs had their first sexual encounter at a younger age, had a greater number of sexual partners, and were more likely to pay for sex and perform unprotected anal intercourse.However, Arab sexual minority men were less likely to perform receptive anal intercourse and were less likely to engage in group sex than Jewish sexual minority men (Mor et al., 2016).

Pre-exposure prophylaxis use
In the only study where authors investigated factors associated with willingness to take pre-exposure prophylaxis, 72% of young sexual minority men reported that it was very/somewhat likely that they would use pre-exposure prophylaxis.Knowledge of HIV risk, awareness of pre-exposure prophylaxis, having had recent condomless anal sex with partners whose HIV status was positive or unknown, and use of substances just prior to or during sex were all positively correlated with greater willingness to use pre-exposure prophylaxis (Storholm et al., 2019).

Gender minority participants
All studies with gender minority participants (transgender, transsexual, and hijras) were conducted in Pakistan, Lebanon, or Iran.Among transgender samples, the mean age of first sexual encounter ranged from 14 years to 16 years (Hawkes et al., 2009;Moayedi-Nia et al., 2019;Saleem et al., 2008), and 18% reported forced first sex (Hawkes et al., 2009).As noted earlier, the language used in some studies is not consistent with language used in most Western studies and, in some cases, may also seem outdated, incorrect, or imprecise.For example, Akhtar and colleagues (Akhtar et al., 2012) referred to their participants as transgender men when describing transgender women.Participants were described as "transgender men (males by nature but appearing as women); including a few individuals whom [sic] had undergone physical transformations through sex reassignment surgery, use of hormones or silicone fillings (p.1)."

HIV rates and testing
HIV rates were similar between transgender sex workers (1% -22%) (Altaf et al., 2012;Bokhari et al., 2007;Hawkes et al., 2009;Khan et al., 2008;Melesse et al., 2016;Reza et al., 2013) and transgender individuals (2% -22%) (Akhtar et al., 2012;Kaplan et al., 2016;Moayedi-Nia et al., 2019).Among transgender sex workers living with HIV, 17% had been diagnosed recently with HIV, whereas 83% had chronic HIV infections (Hasan et al., 2018).Although a diagnosis of HIV added to the social stigmatization of transgender sex workers, many clients continued to have sex with transgender sex workers despite knowledge of their HIV status.Transgender sex workers reported experiencing humiliation from their fellow transgender sex workers after their HIV diagnosis, which forced them to be socially isolated (Usman et al., 2018).HIV testing ranged from 7% to 14% among Pakistani transgender sex workers (Altaf et al., 2012;Collumbien et al., 2008;Hawkes et al., 2009) to 43% among transgender women in Lebanon (Kaplan et al., 2016).In two studies, researchers adapted and tested an HIV prevention intervention, TransAction (Baynetna), to assess feasibility and acceptability among transgender women in Lebanon.Participants in these studies evaluated the intervention to be feasible and acceptable, and HIV testing increased among study participants (Kaplan et al., 2020;Kaplan et al., 2019).

HIV, sexually transmitted infections, and condom knowledge
Similar to research among cisgender sexual minority men, knowledge regarding HIV, sexually transmitted infections, and condom use was measured differently across studies, and results were mixed.Overall good HIV and sexually transmitted infection knowledge (transmission, prevention, condom use, treatment) ranged from 31% to 78% across studies (Hawkes et al., 2009;Khan et al., 2008;Saleem et al., 2008;Shaw et al., 2011).For example, in one study, most participants (68%) had heard of HIV and associated HIV risk reduction with condom use (69%), avoidance of anal sex (73%), or needle sharing (87%) (Khan et al., 2008).

Other sexual risk behaviors
In one study, 3% of transgender sex workers reported having unprotected sex with people who injected drugs and shared needles (Melesse et al., 2018).Since most studies in Pakistan involved transgender sex workers, the number of sex partners was high and ranged from 4 partners/week to 18 partners/month (Altaf et al., 2012;Bokhari et al., 2007;Saleem et al., 2008).
Transgender women described multiple factors related to sexual risk behaviors, including lack of social, emotional, physical, and financial safety; they also reported coercive sex and inability to consistently use condoms because of stigma and fear of being judged (Kaplan et al., 2015).They described using high-risk and unprotected sexual relationships as a way to be accepted aswomen, to make money, for protection, and to obtain shelter.In evaluating the risks of unprotected sex, participants noted that the risk of HIV was less important than their other problems, such as depression and hopelessness (Eftekhar et al., 2020).Notably, there were no studies of pre-exposure prophylaxis use or knowledge among transgender people, despite their engagement in high-risk behaviors.

Mental health
In 20 of the studies reviewed, researchers focused on mental health.These studies were conducted in Iran (n = 8), Lebanon (n = 6), Pakistan (n = 5), and Kuwait (n = 1).We first describe the studies conducted with sexual minority participants (n = 7), followed by studies conducted with gender minority participants (n = 13).

Depression, anxiety, and suicidal thoughts and behaviors
Compared to heterosexuals, sexual minority individuals reported higher levels of anxiety (Nematy and Oloomi, 2016), social isolation, feelings of defectiveness/shame, and emotional inhibition (Nematy et al., 2014).There was no significant difference in attachment styles (defined as closeness, dependency, and anxiety) between bisexual/lesbian women and gay men (Nematy and Oloomi, 2016).It is notable that this was the only study in which researchers reported data on mental health among sexual minority women.Among sexual minority men, depressed mood was reported by 41% of the sample, with 26% having symptoms consistent with a clinical diagnosis of depression and 16% having major depression (Wagner et al., 2019).One third of sexual minority men (33%) reported suicidal thoughts, including having a plan (Wagner et al., 2019).

Mental health risks and buffers
Sexual minority individuals whose families were not aware of their sexual identity scored significantly higher on social isolation, vulnerability to harm/illness, and emotional inhibition than those whose families were aware (Nematy et al., 2014).Although sexual minority participants generally endorsed low levels of internalized homonegativity (Michli and El, 2020), those who reported less comfort with their sexual identities reported higher levels of anxiety (Nematy and Oloomi, 2016).Sexual minority individuals also reported high levels of parental rejection (Michli and El, 2020) and significant conflicts and tensions between their sexual and religious identities (Scull and Mousa, 2017).Sexual minority individuals described risks associated with their sexual identities (such as fear of living openly or someone discovering their sexual orientation) and highlighted the need to build accepting sexual minority communities (Scull and Mousa, 2017).Sense of belonging to a community buffered the impact of internalized homonegativity (Michli and El, 2020).Although the above mentioned researchers (Michli and El, 2020;Nematy and Oloomi, 2016;Nematy et al., 2014;Scull and Mousa, 2017) included sexual minority women in their overall sample, none disaggregated the findings.
Unemployment, lack of legal resident status, discrimination experiences, discomfort with being a sexual minority, and lack of social support were significantly associated with major depression among sexual minority men (Wagner et al., 2019).Participants described experiencing multiple forms of stigma and discrimination at home and in the workplace or at school; these experiences negatively impacted self-esteem and mental health and increased internalized homophobia.Coping mechanisms included concealing sexual minority status, turning to the internet for social and sexual networking, avoiding in-person social relations, focusing on work and academic performance, stepping back from religion, and using alcohol (Wagner et al., 2013).Psychological well-being among sexual minority men was described in terms of relationships with and disclosure of sexual identity to family, friends, and co-workers.More than half of sexual minority men (61%) reported close relationships with their families that were supportive and affectionate and also reported that they were able to disclose their sexual orientation to at least one member of their family; fewer participants disclosed their sexual identities to friends or co-workers (32%) (Wagner et al., 2013).Participants described the importance of a safe space, finding other sexual minority men, balancing safety with visibility, and the struggles they faced in finding support within the sexual minority community (Mutchler et al., 2018).

Mental health risks and buffers
In Pakistan, transgender participants described early realization of their differences, which was accompanied by physical and psychological reprimands from their family; they also described poor living conditions, feeling lonely, and anticipating dying in isolation (Abdullah et al., 2012).Almost half of transgender participants (46%) reported a medium level of psychological resilience while 25% reported a high level; similarly, 44% of transgender participants reported a medium level of self-esteem while 26% reported a high level (Akhtar and Bilour, 2020).Transgender participants residing with their gurus had a significantly higher level of psychological resilience and self-esteem compared to those living alone or with friends (Akhtar and Bilour, 2020).In one intervention study, researchers used an empowerment model-based training to improve quality of life among transgender individuals in Iran (Asadi et al., 2020).The treatment group showed statistically greater improvement on quality of life and mental health than the control group.

Violence and discrimination
In seven studies (five in Pakistan and two in Lebanon), researchers investigated different forms of violence and discrimination.We first describe the studies conducted with sexual minority participants (n = 4), followed by the studies conducted with gender minority participants (n = 4).There is one overlapping study that included sexual and gender minority participants.

Sexual minority participants
All research on violence among sexual minority people involved sexual minority men.Rates of sexual abuse (sexual harassment, rape, forced sex) tended to be high among sexual minority men, ranging from 11%− 49% (El Khoury et al., October 2019;Mayhew et al., 2009;Orr et al., 2019).In one study, 17% of the participants were younger than 13 when they first experienced sexual violence (El Khoury et al., October 2019); similarly in another study, participants described being raped and sexually abused during early childhood while working as truck cleaners/helpers (de Lind van Wijngaarden and Schunter, 2014).Being sexually abused as a child was associated with experiencing more types of sexuality-related discrimination in the past year and being in an abusive relationship (El Khoury et al., October 2019).Other forms of abuse were also high; verbal abuse ranged from 42%− 56% (Mayhew et al., 2009;Orr et al., 2019) and physical abuse from 26%− 44% (Mayhew et al., 2009).Participants also described multiple forms of abuse by the police that ranged from 11% to 50% (Mayhew et al., 2009).In Lebanon, foreign-born sexual minority men were twice as likely as native-born sexual minority men to report any type of discrimination or violence (Orr et al., 2019).

Experiences with the healthcare system
In only two studies, researchers investigated experiences of sexual and gender minority people with the healthcare system.In Lebanon, researchers found that most sexual and gender minority participants reported anticipation of discrimination and negative and positive experiences with healthcare providers and systems.They described their expectations of affirming providers as respectful, inclusive, and knowledgeable.In this study, transgender participants, especially refugee transgender women, reported unique challenges, stigma, and discrimination (Abboud et al., 2020).Transgender participants in Iran perceived psychiatrists as being more empathetic, non-discriminatory, and providing better care to transgender participants than other healthcare providers (Jazi et al., 2015).

Studies about gender
In 17 studies (11 in Iran, five in Pakistan, and one in Lebanon), researchers focused on different aspects of gender among gender minority individuals.
S. Abboud et al. 3.13.1. . Gender identity In a comparative study between transgender individuals living in Iran and transgender individuals living in the Netherlands, Iranian participants had significantly higher rates of gender dysphoria and psychological symptoms than Dutch participants (Shirdel-Havar et al., 2019).In a study of transgender people in Lebanon, all (N = 28) participants reported experiencing a desire to be a different gender from adolescence to adulthood, and almost all (n = 27) reported discomfort with different aspects of their bodies (Khoury et al., 2021).

. Gender roles
In three studies in Iran, researchers compared gender roles between cisgender and transgender participants (Alavi et al., 2015;Khorashad et al., 2019;Roshan et al., 2019).For example, Alavi and colleagues reported that compared to cisgender male and female participants, transgender participants had the highest and lowest score on the Gender Masculine scale, respectively; transgender men had the lowest score on the Gender Feminine scale of all groups (Alavi et al., 2015).

Gender affirming treatments
In several studies, researchers compared transgender individuals undergoing different treatments and found that quality of life and body image scores were significantly higher among those who underwent gender-reassignment surgery than those who received only hormone therapy or who received no treatment (Fallahtafti et al., 2019;Mofradidoost and Abolghasemi, 2020;Naeimi et al., 2019;Simbar et al., 2018).Transgender men undergoing or planning to undergo medical transition described their identities in terms of manliness (manlier than cisgender men), realness (they are "real" transgender people compared to "fake" transgender women), and psychological wellness (Saeidzadeh, 2020).

Quality of life
In one study of transgender people in Iran, a majority of participants had at least a high school diploma (77%), lived in urban areas (82%), were employed (57%), were single (93%), and reported less than six months of hormonal treatment (61%) (Hedjazi et al., 2013).Compared to the general population, quality of life of transgender participants was significantly lower in multiple dimensions including physical functioning, social functioning, role limitations, and vitality (Valashany and Janghorbani, 2018).When asked about their lived experiences related to gender, transgender individuals described loss of self-confidence, loss of legal-self, and loss of social esteem (Mohammadi, 2018).Transgender participants in Pakistan described various forms of rejection, discrimination, violence, and abuse from family members during childhood and from the general community and in the workplace during adulthood; elderly participants also reported difficult circumstances due to extreme poverty, disease, isolation, and lack of support (Alizai et al., 2017;Collumbien et al., 2009;Irshad et al., 2020).A majority (63%) of participants in a study of transgender people in Pakistan reported fully concealing their transgender identity in work and non-work domains; disclosure was influenced by the complexities of family honor, tightly integrated family networks, social obligations to get married, and national religious beliefs (Saeed et al., 2018).In addition, participants (93%) experienced social rejection from family, friends, or co-workers because of their gender identity (Khoury et al., 2021).

Discussion
Our goal in this scoping review was to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.Based on our review, we found that there were major gaps in the literature.An important one was the paucity of research conducted with sexual minority women; only five studies included women, and only one of these focused on sexual minority women.Researchers in the Middle East and North Africa have focused predominately on sexual minority men and transgender women.Another significant gap was the lack of focus on health issues beyond sexual behaviors and sexual health.We did not find a single paper focused on an aspect of physical health apart from sexual health.
We found the need to address the high rates of HIV and other sexually transmitted infections, low rates of both condom use and HIV/sexually transmitted infection testing, and lack of appropriate knowledge related to HIV and sexually transmitted infection prevention and treatment, including pre-exposure prophylaxis.In only one study, researchers addressed pre-exposure prophylaxis intake among sexual minority men and found high willingness to take it (Storholm et al., 2019); however, other factors associated with pre-exposure prophylaxis, such as cost, availability, and access, need to be investigated among sexual and gender minority people who are at high risk for HIV.
Mental health concerns, including depression, anxiety, and suicidal thoughts and behaviors, appear to be prevalent among sexual and gender minority people in the Middle East and North Africa.Although family and community support was highlighted as a buffer, family rejection, conflicts between sexual identity and religion, and challenges in finding community were common issues and concerns.Sexual and gender minority people also reported high rates of discrimination and alarming rates of violence, particularly among the most vulnerable groups, such as youth, gender nonconforming people, and refugees.We found only one intervention study in which researchers aimed at improving mental health, which, although successful, included only transgender people in Iran (Asadi et al., 2020).In another intervention study (among transgender people in Lebanon), researchers focused on improving sexual health outcomes but also showed improvement in mental health outcomes (Kaplan et al., 2020;Kaplan et al., 2019).Missing from the literature are larger-scale studies among sexual and gender minority people in the region to provide more precise information about rates of mental health concerns, as well as risk and protective factors associated with such concerns.Research on the mental health of sexual minority women and studies with comparison of samples based on gender and sexual identity are greatly needed.
In general, sexual and gender minority people access healthcare at lower rates than cisgender heterosexual people (Kates et al., 2018;Macapagal et al., 2016;Ward et al., 2014).The reasons are multifactorial.However, lack of culturally competent care is a large barrier to accessing healthcare (Brummett and Campo-Engelstein, 2021;Göçmen and Yılmaz, 2017;Kattari et al., 2021).Access to gender affirming treatments is associated with improved quality of life, amplifying the need for affirming and competent healthcare for gender minority people globally, but perhaps particularly in the Middle East and North Africa.It is noteworthy that in only two studies, researchers examined healthcare experiences.Understanding the unique experiences of sexual and gender minority people in the region has important implications for educational and curricular reform and training of current and future healthcare providers.Based on existing research, sexual and gender minority-specific training of healthcare providers can increase knowledge and awareness of sexual and gender minority health issues and contribute to affirming and inclusive care (Elertson and McNiel, 2021;Fauer et al., 2020;Gibson et al., 2020).

Gaps in country representation
All except 10 of the studies reviewed were conducted in Lebanon, Pakistan, or Iran, which may provide a highly skewed picture of sexual and gender minority health in the region.As noted earlier, same-sex relationships and gender non-conformity are criminalized in almost all countries in the Middle East and North Africa.These laws make it nearly impossible for advocacy organizations to work on issues related to sexual orientation and gender identity and make it challenging for researchers to conduct research with sexual and gender minority people (Human Rights Watch 2018).Nearly all (20 of 23) studies conducted in Iran focused on transgender individuals.This may be because Iran is one of two countries in the region to provide transgender individuals the conditional right to have their identity recognized by the law (Being Transgender in Iran 2016).However, the conditions for actualizing that right (psychiatric diagnosis of gender identity disorder and completion of gender affirming surgery) reinforce the belief that transgender people are psychologically and sexually unfit and require treatment to become "normal."Similarly, there were also a large number of studies (28 of 32) in Pakistan conducted with transgender individuals.In 2018, the Pakistani parliament passed the "Transgender Persons (Protection of Rights) Act" which established broad protections for transgender people.As demonstrated in this review, despite the implementation of these laws in Iran and Pakistan, transgender people continue to face stigma and discrimination based on their gender identity.
Most of the research conducted in Lebanon was among sexual minority men (23 of 33 studies).Despite social, religious, and legal conservativism, Lebanon has witnessed growing advocacy, research, and visibility of sexual minority people relative to other countries in the region (Moussawi, 2017).This has allowed researchers to conduct studies, many in collaboration with sexual and gender minority-friendly community-based organizations (for example, see Kaplan and colleagues' study with transgender women) (Kaplan et al., 2020).
Based on the identified research gaps, recommendations include expanding research beyond Lebanon, Pakistan, and Iran to represent more countries in the Middle East and North Africa.This could include collaborations between researchers and communitybased organizations from different countries and exchanging lessons learned in the areas of sexual and gender minority health research.

Gaps in methodological designs
Most of the studies used cross-sectional quantitative designs, and only two studies tested an intervention (Asadi et al., 2020;Kaplan et al., 2020;Kaplan et al., 2019).This highlights the need for additional qualitative or mixed-methods research to better understand the complexities of the experiences of sexual and gender minority individuals; there is also a need for longitudinal studies to understand the impact of societal and legal changes on sexual and gender minority health over time.Most studies used non-probability sampling, and only five studies used stratified random selection.This type of sampling is used widely with hard-to-reach populations and can provide valuable information; however, non-probability sampling methods are subject to selection bias, and it is not possible to know the extent to which the findings accurately represent and characterize sexual and gender minority populations.Although challenging, researchers should advocate that measures of sexual orientation and gender identity be included in country-level surveys, especially nationally representative studies.
Development and implementation of multi-level interventions are needed to prevent and address the adverse sexual and gender minority health outcomes.In the two intervention studies (Asadi et al., 2020;Kaplan et al., 2020;Kaplan et al., 2019) included in this review, researchers showed promising improvements in quality of life and in the emotional, mental, and sexual health of transgender individuals.Given the challenges in conducting this type of research in the region, we highly encourage researchers to employ participatory approaches that involve multiple stakeholders from the community to develop and implement interventions, ensure trust and representation of sexual and gender minority individuals, and establish longstanding relationships (Northridge et al., 2007;Wright et al., 2017).

Gaps in representation and measurement of sexual and gender minority identities
Although the number of studies with sexual and gender minority individuals is growing in the region (11 studies between 2000 and 2010 compared with 87 studies between 2011 and 2021), only one exclusively focused on cisgender sexual minority women (Gereige et al., 2018).Researchers in five studies included sexual minority women in their overall sample, but none disaggregated the findings (Abboud et al., 2020;Michli and El, 2020;Nematy and Oloomi, 2016;Nematy et al., 2014;Scull and Mousa, 2017).Only 10 studies included transgender men.This highlights the need for more inclusive research of the multiple sexual and gender minority identities, particularly cisgender sexual minority women and transgender men.We also recommend better measurement of sexual orientation.Although sexual orientation consists of at least three overlapping but distinct dimensions (identity, attraction, and behavior), most researchers assessed only one dimension-mostly sexual behavior (e.g., men who have sex with men).
Another limitation is the conflation of sexual minority men and transgender women as sexual risk categories in multiple studies.Future researchers needs to acknowledge that sexual health risks and protective factors impact sexual minority men and transgender women differently and that these identities should be seen as having unique risks and resiliencies (Kaplan et al., 2016;Perez-Brumer et al., 2016;Poteat et al., 2016).
Several studies used outdated terminology when describing gender minority individuals.In a few studies conducted in Pakistan with transgender women, researchers referred to their participants as transgender men in reference to their assigned (male) sex at birth (see for example, Akhtar and colleagues) (Akhtar et al., 2012).In Iran, some researchers investigated personality disorders among transgender participants and referred to their participants' early questioning of their gender identity as early onset of "symptoms."(Meybodi et al., 2014;Shirdel Havar et al., 2015) As mentioned earlier, this type of research or terminology reinforces stigma and stereotypes about transgender people and contributes to these individuals' emotional and psychological concerns.

Gaps in measuring different health outcomes
Although researchers assessed multiple health outcomes in many studies, more than half of the studies (53%) focused on sexual health.However, none of the studies addressed positive aspects of sexual health, such as pleasure, communication, or healthy relationships.In addition, none of the studies focused on physical health outcomes, such as cancer, diabetes, or cardiovascular issues.Although in several studies researchers assessed health behaviors, such as smoking or alcohol and other drug use, no study had as a primary objective understanding antecedents or consequences of these health behaviors.In very few studies, researchers assessed protective factors, such as coping, family acceptance, social support, and community belonging.More research is needed to understand the role of these protective factors-information that is essential in the development of prevention and intervention strategies.
We found a few studies where researchers focused on individual-level minority stress (e.g., as identity concealment, internalized homonegativity), but none of the researchers focused on the impact of structural-level minority stressors on sexual and gender minority health.In the Middle East and North Africa, where anti-sexual and gender minority laws and norms are widespread, identifying appropriate ways to assess structural stigma and its health consequences is critically important in the development of interventions that mitigate the impact of structural stigma.

Limitations of this scoping review
To our knowledge, this was the first review where the aim is to systematically examine research on sexual and gender minority health in the Middle East and North Africa.We used a systematic search strategy that can be replicated, which will facilitate similar future reviews.However, there are some limitations that should be considered in evaluating our findings.First, we limited our review primarily to studies published in English.Six studies in other languages were excluded, and these may have contained relevant information.It is also possible that searches of four databases did not identify all eligible articles.We excluded gray literature such as dissertations, guidelines, and reports.In recent years, there has been an increasing number of community-based organizations conducting research with sexual and gender minority people in the Middle East and North Africa.For example, the Heartland Alliance International published in an on-line report the needs, vulnerabilities, and experiences of sexual and gender minority Syrian refugees in Lebanon (Heartland Alliance International 2014).It should also be noted that none of the authors currently lives in the Middle East and North Africa.Although two authors were born and raised in Lebanon and continue to be involved in sexual and gender minority research and advocacy in Lebanon and the region, our inclusion/exclusion criteria and methods of reporting the findings through a largely Western lens may not reflect priorities of sexual and gender minority communities in the region.Finally, there isn't a single definition of the Middle East and North Africa, leading to differences regarding which countries should be included.

Conclusion
In this scoping review, we highlighted an increasing interest in sexual and gender minority health in the Middle East and North Africa, as evidenced by the growing number of research articles published, especially in the last decade.However, researchers have mostly studied sexual and gender minority health in three countries and have focused almost exclusively on sexual minority men and transgender women.The breadth of research is limited, with the majority of researchers measuring sexual health outcomes.As is the case in many other regions of the world, research on sexual and gender minority health in the Middle East and North Africa relies almost exclusively on cross-sectional designs.Based on research gaps identified in this review, recommendations include: 1) expanding research beyond Lebanon, Pakistan, and Iran to represent more countries in the region; 2) expanding research beyond sexual minority men and transgender women samples and avoiding the conflation of these identities in studies of sexual risks; 3) investigating health outcomes beyond sexual health and risk behaviors; and 4) increasing the number of studies that use longitudinal designs and that develop and test interventions.Adding questions about sexual and gender identity on national health surveys would provide critically important information that could be used to inform health policy and interventions.Nurses and other healthcare providers need to be educated about the prevalence of health disparities in this population.Nurses play a significant role in health promotion efforts and in

Fig. 1 .
Fig. 1.PRISMA flow diagram for scoping review showing literature search and selection.SGM: sexual and gender minority; MENA: Middle East and North Africa.

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.Abboud et al.

Fig. 2 .
Fig. 2. Heat map of number of research articles in each country in the MENA region.

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Case-control study Age: Mean = 24 Gender: Transgender Sexual orientation: Not specified Sample size: N = 71 Age: No specific restriction Gender: Cisgender men and women, and transgender women Sexual orientation: Not specified Sample size: N = 1541

Table 2 (continued ) First Author (Year); Country
A total of 1.5% were considered to be HIVpositive.Two tested positive for Hepatitis B virus and 3 for syphilis.49%participantsreportedever having had a specific sexually transmitted infection, with the most common being genital lice (33%), gonorrhea (27%), chlamydia (19%), genital warts (14%), and human papilloma virus (9%).13Maatouk(2014);Lebanon Report on characteristics of 5 patients with syphilis in a Lebanese hospital Design: Qualitative study Age: No specific restriction Gender: Cisgender men Sexual orientation: Must have had sex with men Sample size: N ¼ 5

Table 2
(continued ) Investigate the prevalence and correlates of HIV testing and condom use among Iraqi, Syrian, and Palestinian men who sex with men refugees in Beirut, Lebanon Method: Quantitative cross-sectional Age: Mean = 27; range: 18-40 Gender: Cisgender male Sexual orientation: Homosexual Sample size: N ¼ 150 76.6% of the overall participants reported condomless receptive sex and 59.3%

Table 2
(continued ) Assi (2019)ntitative cross-sectional Age: 18 years and older Gender: Cisgender women Sexual orientation:Heterosexual,  bisexual, lesbian, and other (queer).Sample: N = 95 participants Sexual minority women were on average 19 years at their sexual debut with men, significantly younger than heterosexual women's age of 21.Combining both male and female partners, sexual minority women had a significantly higher number of lifetime sex partners of either sex.More than 50% of sexual minority women reported some form of unwanted sexual contact in their lifetime, compared to 23% of heterosexual.25Assi(2019);Lebanon Assess the prevalence of HIV and sexually transmitted infections among men who have sex with men in Lebanon.Design: Quantitative cross-sectional Age: Mean = 26; range: 15-69 Gender: Cisgender man Sexual orientation: Men who sex with men Sample Size: N = 2238 Prevalence of sexually transmitted infections: HIV: 5.6%; human papilloma virus: 41.0%; gonorrhea and/or chlamydia: 17.5%; syphilis: 3%.Condom use: Majority had inconsistent condom-use (67%), 78% had more than one sexual partner in the last three months.The majority reported unprotected oral and anal sex exposures in the past three months (99% and 53% respectively).26 Kaplan (2019); Lebanon Explore the feasibility and acceptability of the adapted intervention TransAction (Baynetna), an HIV prevention intervention for transgender women Design: Mixed-methods Age: Median = 26; range: 22-50 Gender: Transgender women Sexual orientation: Not specified Sample size: N = 16 To pilot test an adapted intervention, ''Baynetna'' to assess preliminary impact Design: Mixed-methods experimental design At the 6-month post-test, 7 out of 13 participants had improved gender (continued on next page) S. Abboud et al.

Table 2
(continued ) Design: Quantitative cross-sectional Age: No restrictions were reported Gender: Cisgender male Sexual orientation: Must have had sex with a man Sample size: N = 1364 Method: Cross-sectional quantitative Age: 15 years and older Gender: Cisgender male and female Sexual orientation: Homosexual and heterosexual Sample size: N = 541 (continued on next page) S. Abboud et al.

Table 2
(continued ) Design: Mixed-methods Age: Not specified Gender: Cisgender male and transgender participants Sexual orientation: Homosexual Sample Size: N ¼ 30 for qualitative interviews; N = 918 (continued on next page) S.Abboud et al.